Section 1200-13-09-.14 - METHOD FOR PAYING PROVIDERS WHICH ARE EXEMPT FROM PROSPECTIVE SYSTEM(1) The Comptroller of the Treasury, will determine, in accordance with Medicare principles of cost reimbursement in effect on October 1, 1982, and described at 42 CFR Part 405, per diem reimbursable costs for those Medicaid providers of psychiatric hospital services exempted from the prospective system set out in Rules 1200-13-9-.06 through 1200-13-9-.12 inclusive, except those hospitals described in item (3) of Rule 1200-13-9-.07 which shall be reimbursable as described in that item. The maximum limit of such reimbursable costs shall be the lessor of: (a) the reasonable cost of covered services, or (b) the customary charges to the general public for such services. Provided, however, that such providers which are public hospitals rendering services free or at a nominal charge shall not be subject to the lower of cost or charges limitation but shall be paid fair compensation for services in accordance with provisions of 42 CFR Part 405 in effect on October 1, 1982. Covered services means covered services as defined by the Department. Each provider's per diem reimbursable cost will be based on the provider's cost report which is to be filled out and submitted in accordance with Rule 1200-13-9-.04.(2)Interim Rate. The Comptroller of the Treasury will establish interim per diem reimbursable rates for providers "exempted from the prospective payment system. The interim rate remains in effect until the provider's actual reimbursable cost, based on the provider's cost report, is established. Interim rates shall be based on prior cost report data and shall be subject to revision upon further review, audit, and/or subsequent finding of the Comptroller of the Treasury. For new facilities, budgeted information supplied by the provider may be used to establish an interim rate.(3)Approval of Initial Settlement.When a provider's cost report is received, it is reviewed and compared with:
(a) The amount of charges for covered services provided to Medicaid beneficiaries by the provider during the provider's fiscal period.(b) The amount of interim payments paid by the Department to the provider for the provider's fiscal period.(c) The number of inpatient days approved for the provider by the Department during the provider's fiscal period. On the basis of the comparison and review, the Comptroller of the Treasury will make an initial determination of the cost settlement due to the provider or the state for the designated period. Approval of the initial settlement will be subject to further review, audit, and/or subsequent finding of the comptroller of the Treasury. On the basis of the initial settlement, the Department or the fiscal agent will (as may be required) either make arrangements for an additional payment to the provider for services provided during the fiscal year or submit a claim to the provider requesting payment to the Department for the amount of overpayment to the provider during the fiscal year.
(4)Approval of Final Cost Settlement. After the necessary final review and/or auditing has been performed by the Comptroller of the Treasury, the Comptroller will advise the Department of the final cost settlement approved. On the basis of the approved final settlement, the Department or the fiscal agent will (as may be required) either make arrangements for an additional payment to the provider for services provided during the fiscal year or submit a claim to the provider requesting payment to the Department for the amount of overpayment made to the provider during the fiscal year.(5)Inpatient Routine Operating Per Diem Cost Limitation. In the event that data is not available to compute the inpatient routine operating per diem cost limitation for all or any part of a provider's fiscal year, the Comptroller of the Treasury will use each provider's per diem cost limitation in effect prior to the provider's first fiscal year subject to prospective payment which will be appropriately trended, by that rate of increase on prospective payments allowed by Medicare as published annually in the Federal Register and in the Tennessee Administrative Register.Tenn. Comp. R. & Regs. 1200-13-09-.14
Original rule filed June 2, 1988; effective July 17, 1988. Amendment renumbering 1200-13-.10 through 1200-13-.14 to read 1200-13-.11 through 1200-13-.15 filed January 29, 1990; effective March 15, 1990.Authority: T.C.A. §§ 71-5-105, 71-5-109 and 4-5-202.